Q: Introduction to perimenopause – when it begins, what are the signs and symptoms?
A: Many women do not realize that menopause does not happen over 24 hours. For a period of 10 to 15 years before menopause is established at the average age of 51, a woman will already be undergoing a period of change in a phase of life known as perimenopause or ‘around menopause’. Perimenopause is typically experienced by women aged between 40 and 56.

Functional capacity (FC) in active postmenopausal women depends more on lower limb muscle strength than on abdominal obesity, suggesting that those with abdominal obesity may not necessarily have a reduced FC as long as lower limb muscle strength is preserved, according to a study.

This review article outlines the prevalence of nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum (HG), definition of NVP and HG, aetiology, risk factors, complications of HG, recommended investigations, primary care management, hospital and ambulatory daycare, therapeutic management of HG supported by good clinical evidence, discharge planning, and importance of the multidisciplinary team to provide high quality care in patients with NVP and HG.

Polycystic ovary syndrome (PCOS) is a health problem caused by an imbalance of reproductive hormones that affects about one in 10 women of childbearing age. With PCOS, the eggs in females may not develop as it should or it may not be released during ovulation. This leads to irregular periods, subfertility, and the development of “cysts” at the periphery of the ovary.

Often times, we associate this hormonal disorder with adult women and how it is the primary cause of their subfertility. Rarely do we hear discussions about the possibilities of adolescent girls developing PCOS, primarily because some symptoms of PCOS in adolescent girls mimic pubertal changes such as anovulatory cycles with menstrual irregularity, and polycystic ovary morphology – causing misdiagnoses of PCOS in the said age group.

“Clinicians may be apprehensive to diagnose PCOS in adolescent girls as many features used for diagnosing adult PCOS are normal findings in a developing teenage girl,” explained Dr Tan Toh Lick, consultant obstetrician and gynaecologist at Thomson Women’s Clinic and Thomson Wellth Clinic.

“In addition, some adolescents may start taking combined oral contraceptive pills, thereby masking the persistence of hyperandrogenism and menstrual irregularities. This is why it is not uncommon to find adults eventually diagnosed with PCOS sharing a history of menstrual irregularity, moderate-severe hirsutism, and acne in their teens,” said Tan.

Having said that, Tan enumerated tell-tale signs physicians can watch out for in diagnosing PCOS among adolescent girls. These include an otherwise unexplained combination of abnormal uterine bleeding pattern persistent for more than 1 to 2 years, evidence of hyperandrogenism through either persistent elevated testosterone level, moderate-to-severe hirsutism or inflammatory acne vulgaris.

In comparison, adults with PCOS display two out of three features of oligo-amenorrhoea: clinical, and biochemical hyperandrogenism, and ultrasound features of polycystic ovaries.

Multidisciplinary care

Adolescents with PCOS may have to seek help from doctors of various specialties due to its complex management requirements.

“Endocrinology is the most common specialty I would refer to exclude other causes of hyperandrogenism, or manage diabetes. Those with hypertension and dyslipidaemia may initially be managed by general practitioners or referred to a cardiologist,” said Tan.

In cases of morbidly obese women, weight reduction medication may be employed in addition to exercise and improving diet. Where these fail, patient may be referred for gastric banding, or bariatric surgery to optimize weight and reduce complications of the hormonal disorder.

He adds: “For women who have anovulatory subfertility not responding to ovulation induction, they may require comanagement with assisted conception units for in vitro fertilization (IVF) consideration.”

Dietary and lifestyle modifications

While there is no known cure for PCOS, good control of symptoms and risks may be achieved with lifestyle changes and proper maintenance of medications. Adolescents with PCOS face increased risks of metabolic syndrome, insulin resistance that may lead to type 2 diabetes mellitus, cardiovascular diseases, and endometrial carcinoma.

To reduce these long-term health risks, Tan noted that the most important measure for these adolescents is to adopt a healthy lifestyle. He advised that they should consume moderate amount of lean meat, fish, vegetables, and whole foods such as brown rice and fruit, and avoid eating too much.

“It is also important for the individual to exercise regularly for at least 30 minutes thrice weekly to improve cardiovascular function and optimize weight. She should also aim for a healthy body mass index (BMI) of between 19 and 25.”

Treating PCOS

Aside from altering some lifestyle and dietary options for adolescent patients, PCOS may be controlled depending on the adolescent’s desire to control her symptoms. For example, the combined contraceptive pill (COCP) helps in correcting menstrual abnormalities and hyperandrogenism —although some patients may find such treatment not personally or culturally acceptable for them.

“Menstrual irregularities should be treated to reduce risk of anaemia, endometrial hyperplasia, as well as psychosocial morbidity. The COCP or progestin-only regimens are generally effective and often employed. For adolescents who do not have menses for over 4 months and experience irregular or heavy bleeding, it is advisable to have an ultrasound scan to screen for cancer of the womb. Endometrial sampling and hysteroscopy should be considered if the endometrium is thickened or suspicious-looking. Treatment for these abnormal uterine bleeding can reduce this risk. Tranexamic acid during menses may also be used to reduce heavy menstrual bleeding in those not keen to take COCP,” explained Tan.

Adolescents with PCOS who exhibit symptoms like hirsutism and inflammatory acne vulgaris may seek cosmetic procedures, as well as topical and oral medications, to control the abovementioned symptoms.

Physicians must also keep in mind that depression and snoring are associated with PCOS. Screening and appropriate referral will enable management of these issues, Tan concluded.
MIMS

Q: Introduction to perimenopause – when it begins, what are the signs and symptoms?
A: Many women do not realize that menopause does not happen over 24 hours. For a period of 10 to 15 years before menopause is established at the average age of 51, a woman will already be undergoing a period of change in a phase of life known as perimenopause or ‘around menopause’. Perimenopause is typically experienced by women aged between 40 and 56.

Functional capacity (FC) in active postmenopausal women depends more on lower limb muscle strength than on abdominal obesity, suggesting that those with abdominal obesity may not necessarily have a reduced FC as long as lower limb muscle strength is preserved, according to a study.

This review article outlines the prevalence of nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum (HG), definition of NVP and HG, aetiology, risk factors, complications of HG, recommended investigations, primary care management, hospital and ambulatory daycare, therapeutic management of HG supported by good clinical evidence, discharge planning, and importance of the multidisciplinary team to provide high quality care in patients with NVP and HG.